Predictive Factors for Persistent Symptoms after Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation: Findings from the Multicenter PRIME-MR Registry

B. Köll (Hamburg)¹, S. Ludwig (Hamburg)¹, J. Weimann (Hamburg)¹, L. Stolz (München)², A. Scotti (New York)³, E. Xhepa (München)⁴, E. Donal (Rennes)⁵, D. Patel (Los Angeles)⁶, T. Tanaka (Bonn)⁷, T. Trenkwalder (München)⁴, F. Rudolph (Bad Oeynhausen)⁸, D. Samim (Bern)⁹, P. von Stein (Köln)¹⁰, C. Giannini (Pisa)¹¹, J. Dreyfus (Paris)¹², J.-M. Paradis (Quebec)¹³, M. Adamo (Brescia)¹⁴, N. Karam (Paris)¹⁵, Y. Bohbot (Amiens)¹⁶, A. Bernard (Tours)¹⁷, B. Melica (Porto)¹⁸, O. De Backer (Copenhagen)¹⁹, Y. Lavie-Badie (Toulouse)²⁰, M. Keßler (Ulm)²¹, C. Iliadis (Köln)¹⁰, S. Redwood (London)²², E. Lubos (Hamburg)²³, M. Metra (Brescia)¹⁴, F. Praz (Bern)²⁴, M. Gercek (Bad Oeynhausen)⁸, G. Nickenig (Bonn)⁷, T. Modine (Bordeaux)²⁵, J. Hausleiter (München)², A. Coisne (Lille)²⁶, D. Kalbacher (Hamburg)²⁷
¹Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ²LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ³Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care New York, USA; ⁴Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland; ⁵University of Rennes CHU Rennes, Inserm, LTSI - UMR 1099 Rennes, Frankreich; ⁶Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles, USA; ⁷Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; ⁸Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ⁹Inselspital - Universitätsspital Bern Bern, Schweiz; ¹⁰Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ¹¹AOUP - Azienda Ospedaliero Universitaria Pisana S.D. Emodinamica Pisa, Italien; ¹²Centre Cardiologique du Nord Cardiology Department Paris, Frankreich; ¹³Laval University Quebec Heart & Lung Institute Quebec, Kanada; ¹⁴University of Brescia Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Brescia, Italien; ¹⁵European Hospital, Georges Pompidou, Paris, France; and the eUniversity of Paris, PARCC, INSERM, Paris, France Advanced Heart Failure Unit Paris, Frankreich; ¹⁶Amiens University Hospital Department of Cardiology Amiens, Frankreich; ¹⁷CHRU de Tours Cardiology Department Tours, Frankreich; ¹⁸Centro Hospitalar Vila Nova de Gaia/Espinho Porto, Portugal; ¹⁹University hospital Copenhagen Copenhagen, Dänemark; ²⁰Rangueil University Hospital Department of Cardiology Toulouse, Deutschland; ²¹Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ²²St. Thomas' Hospital Department of Cardiology London, Deutschland; ²³Katholisches Marienkrankenhaus gGmbH Kardiologie und Angiologie Hamburg, Deutschland; ²⁴Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ²⁵Centre Hospitalier Universitaire Bordeaux Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle Bordeaux, Frankreich; ²⁶Heart Valve Clinic, CHU Lille Department of Clinical Physiology and Echocardiography Lille, Frankreich; ²⁷Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland

Background

Residual mitral regurgitation (MR) post transcatheter edge-to-edge repair (M-TEER) is a strong indicator of adverse events in patients with primary MR (PMR). While M-TEER generally improves MR, a subgroup continues to experience a substantial symptomatic burden, shown by New York Heart Association (NYHA) class III or IV status at discharge. Identifying predictive factors for these persistent symptoms can improve patient selection and post-procedure strategies. This study leverages data from the PRIME-MR registry to identify predictors of persistent symptom burden post M-TEER.

Methods

PRIME-MR is a retrospective, investigator-initiated registry including PMR patients who underwent M-TEER at 24 high-volume centers from 2009 to 2022. After excluding in complete cases, 888 patients were analyzed. Symptomatic status at discharge was classified as NYHA Class I/II or Class III/IV, with the latter indicating symptom persistance. The primary composite endpoint was all-cause mortality or rehospitalization.

Results

Among the 888 patients, 742 (83.6%) achieved NYHA Class I/II, while 146 (16.4%) remained in NYHA Class III/IV. Both groups were similar in age and sex distribution. However, those patients with persistent symptoms had higher initial NYHA classes (NYHA Class ≥III: 93.8% vs. 81.6%; p<0.001) and a shorter 6-minute walk distance (median 158 m [IQR 40, 270] vs. 252 m [137, 329]; p=0.006). Baseline MR severity (median EROA 0.4 cm² [0.3, 0.6]) did not differ ( p=0.81), but symptomatic patients had higher rates of mitral annular calcification (7.1% vs. 2.7%, p=0.023) and a smaller mitral valve orifice areas (4.0 cm² [3.1, 5.2] vs. 4.9 cm² [4.0, 5.8]; p=0.001). Moderate or greater residual MR at discharge was more frequent in symptomatic patients (56.6% vs. 28.9%; p<0.001) and linked to higher all-cause mortality or rehospitalization rates within 2 years (log-rank p<0.0001, Figure 1).

Conclusion

A distinct subset of patients undergoing M-TEER for primary MR does not experience symptomatic improvement at discharge, particularly those with mitral annular calcification and smaller mitral valve orifice areas. This subgroup was at significantly higher risk for mortality or rehospitalization. Tailored risk assessment and management strategies are crucial for improving outcomes in these high-risk patients.

Predictive Factors for Persistent Symptoms after Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation: Findings from the Multicenter PRIME-MR Registry

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